Paying when patients wait

The Daily had an interesting story on a handful of doctors who are paying their patients — either explicitly in cash or in the form of a gift — when they make their patients wait past their appointment times (Their Wait in Gold, Mar 19).

There’s a promising new trend afoot in doctors’ offices around the country: With average wait times growing in recent years, some physicians have begun offering goods, services and even cash to waylaid patients.

“Why is my time more important than my patients?” asked Dr. Cyrus Peikari of Dallas. “True service can only come when we put our egos aside.”

To make up for canceling some appointments last year, Peikari mailed each patient a check for $50.

Dr. Timothy Malia of Fairport, N.Y., keeps a supply of $5 bills on hand. He dispenses them to patients if they’ve been made to wait past their appointment time. …

Nationwide, most patients spend a lot more than 10 minutes waiting to see their doctor. The national average is 24 minutes past the appointment time, up from 18 minutes in 2002 and 16 minutes in 1989, according to studies.

“The trouble with a lot of health care offices is that they are designed by doctors with little training in queuing,” said David Belson, a professor of Industrial and Systems Engineering at the University of Southern California, who studies wait times. “In most business schools, there would be a class on queuing. There’s no need to have a couple of hours worth of patients queued up.”

So let me start by saying that as a patient, I kind of like this. It is nice to hear that MDs take service seriously and are at least somewhat cognizant that patients can have ungodly waits. As a business school professor, however, I think of lots of reasons why you might have “a couple of hours worth of patients queued up.”

First, there is the problem of priorities. In businesses from bowling alleys to restaurants, appointment or reservation holders get priority over walk ins. Time sensitive customers then know they need to ask for service early (i.e., get an appointment) and the firm can focus on providing them responsive service while walk ins make do with whatever capacity is less.

Healthcare doesn’t work that way. In most medical settings, those late in asking for service have urgent needs and thus get priority treatment. Even if there are no urgent walk ins, there are patients with unexpected complications. Someone may be scheduled for a quick ten minute visit but all of a sudden needs an hour of the staff’s time. These per se wouldn’t be a problem but if a system is set up to run at high utilization, it can be fairly fragile with one unexpected complication impacting all of the other patients scheduled for the day.

That gets to the second point. Doctors — particularly in primary care — need to be heavily scheduled. The Wall Street Journal has had a pair of articles in the past week or so that highlight how hard it can be to run a medical practice. The first article (Why America’s Doctors Are Struggling to Make Ends Meet, Mar 16) discusses a practice that has transitioned to be a medical home — coordinating patient care across specialties. Here is the accompanying video.

Vodpod videos no longer available.

So this constitutes better care, but has left the practice essentially as a break-even operation including grants from a non-profit. This raises one of the problems with compensating patients for long waits: It’s just not built into the cost structure. Physicians may enjoy an illusion that they set their prices but for most it is not really so. They are dependent on what insurers will pay and Blue Cross et al ain’t going pony up for a gift to a patient who had a long wait.

A small but growing number of primary-care physicians are changing over to what are often called “concierge” or “retainer” practices, treating a limited number of patients who pay from a few hundred to thousands of dollars a year for more-personalized services.

“On a very basic level, you’re paying for improved access and ease of accessibility,” says Alwyn Cassil, public-affairs director at the Center for Studying Health System Change, a health-policy research firm in Washington.

Hard numbers aren’t available. But the American Academy of Private Physicians, a trade group, estimates that 4,400 doctors now run such boutique practices, with about 1,000 doctors changing their practice in the last year, says Tom Blue, the group’s executive director. …

The trend has picked up steam as stingy insurance reimbursements have squeezed primary-care doctors to the point where many take on a roster of 2,000 to 3,000 patients, seeing upward of 30 a day.

By restricting their practices and charging fees for additional services, they can maintain or improve their incomes with a less-frenzied schedule. Some physicians affiliate with networks or specific companies, while others go it alone.

Health-care consumers can choose whether to pay out of pocket for services, like short office-waiting times, that once were an expected part of the doctor-patient relationship. The most typical cost is about $1,500 a year, or roughly the equivalent of a family cellphone bill, and includes a thorough annual checkup as well as easier access to your physician. Hospitalizations, specialist care and other out-of-office services will cost extra.

Concierge practices are an interesting idea. They clearly highlight the different levels of care that are available and that there are financial gains to segmentation. However, it also shows what it would take to guarantee short waits. Physicians would have to have much, much smaller practices than they currently do. That is not economically sustainable with current compensation from private insurers and government programs. Even if it were, the nation would quickly run out of primary care doctors.

In short, while it is nice to think of your doctor showing some respect for your time, the system is stacked against it unless you are willing to really pay for it.